Active NPI
Drew Michael Wallace, ATC
- Athletic Trainer
- Poplar Grove, IL
National Provider Identifier
1669878625
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Athletic Trainer
- License
- 200014924
- Practice address
- 17823 Poplar Grove Rd
Poplar Grove, IL 61065-9014 - Phone
- (815) 765-3311
- NPI assigned
- Nov 18, 2014
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Athletic Trainer | 2255A2300X | 200014924 | IL | Primary |
Addresses
Primary practice location
17823 Poplar Grove Rd
Poplar Grove, IL 61065-9014
Mailing address
5061 Linden Rd
#5303
Rockford, IL 61109-5834
Phone (815) 878-5391
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 200014924 | IL | MD | Athletic Trainer |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1416268800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1416268800000",
"number": "1669878625",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "5061 LINDEN RD",
"address_2": "#5303",
"city": "ROCKFORD",
"state": "IL",
"postal_code": "611095834",
"telephone_number": "815-878-5391"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "17823 POPLAR GROVE RD",
"city": "POPLAR GROVE",
"state": "IL",
"postal_code": "610659014",
"telephone_number": "815-765-3311"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "DREW",
"middle_name": "MICHAEL",
"credential": "ATC",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2014-11-18",
"last_updated": "2014-11-18",
"status": "A"
},
"taxonomies": [
{
"code": "2255A2300X",
"taxonomy_group": "",
"desc": "Specialist/Technologist, Athletic Trainer",
"state": "IL",
"license": "200014924",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Poplar Grove, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 18, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.